Download diagnosis and treatment of superfical

DIAGNOSIS AND TREATMENT OF SUPERFICAL AND DEEP BACTERIAL
PYODERMA
K. Marcia Murphy, DVM, DACVD
Department of Companion Animals and Special Species
North Carolina State University
College of Veterinary Medicine
4700 Hillsborough Street
Raleigh NC 27606
Superficial pyodermas (impetigo, superficial bacterial folliculitis) are bacterial infections that involve
the epidermis and/or follicular epithelium. Impetigo is characterized by nonfollicular subcorneal pustules that
affect sparsely haired areas of the skin. The primary feature of folliculitis is a tiny, inflammatory pustule with a
hair shaft protruding from the center. Typical pustules may be difficult to find as pustular lesions are very
transient in dogs and cats, especially when the animal is pruritic. More common lesions are follicular papules,
which may or may not be crusted, epidermal collarettes, erythema, hyperpigmentation, and alopecia. In most
cases, coagulase-positive Staphylococcus organisms are involved, with the overwhelming majority of canine
skin infections caused by S. pseudintermedius bacteria.
Successful treatment of bacterial skin infections requires systemic antimicrobial therapy aimed at the
specific etiologic agent. The clinician should prescribe systemic antibiotics that are bactericidal and betalactamase resistant for a minimum of 3-4 weeks. The rule of thumb is to continue systemic antibiotic for 7-10
days beyond complete clinical resolution. Historically, routine bacterial culture and sensitivity was not indicated
in most cases of superficial pyoderma as S. pseudintermedius resistance was low. However, with the increasing
frequency of methicillin-resistant and multi-drug resistant Staph.organisms, bacterial culture and sensitivity
testing would be recommended for those patients who had received systemic antibiotics within the past 6
months. As always, if a patient is not responding to appropriate antibiotic therapy, the first step the clinician
should take is to confirm that the cause of the dermatitis is actually bacterial pyoderma (rule out Malassezia
dermatitis, dermatophytosis, etc.). Cytology should be performed in the case of a patient that has nonresponsive pyoderma. If rods are seen on cytology in addition to cocci, then the staphylococcal pyoderma may
be complicated by a gram-negative infection. In any event, culture and sensitivity should be performed to aid in
antibiotic selection. In the case of recurrent skin infections, the clinician must look for and address the primary
problems that are predisposing to the animal to repeated infections.
Antibiotic choices for skin infections include the cephalosporins, clindamycin, clavulanic-acid–
potentiated amoxicillin, and the fluoroquinolones. Cephalosporins are broad-spectrum, bactericidal antibiotics
with low incidence of staphylococcal resistance. Cefadroxil (22 to 30 mg/kg every 12 hours for dogs; 22mg/kg
every 12 hours for cats), cephalexin (22 to 35 mg/kg every 12 hours), and cefpodoxime (5 to 10 mg/kg every 24
hours) are the most commonly used cephalosporins. Cephadroxil, cefpodoxime and cefovacin are labeled for
veterinary use. Cefovacin is an injectable cephalosporin dosed at 8mg/kg every 14 days.2 All of these drugs are
effective and can be used long-term with a low incidence of side effects. Gastrointestinal signs (inappetence,
vomiting, loose stool/diarrhea) are the most common side effects.
Clindamycin (11 mg/kg every 12 hours or 22 mg/kg every 24 hours for dogs; 5.5 mg/kg every 12
hours or 11 mg/kg every 24 hours in cats) is bacteriostatic, with a spectrum of activity primarily against grampositive bacteria, including Staphylococcus, Streptococcus, Corynebacterium, as well as most pathogenic
anaerobes. Clindamycin is generally well tolerated, although high doses have caused vomiting and diarrhea in
cats. Diarrhea may be seen due to altered bacterial population in the intestine.
Amoxicillin + clavulanic acid (13.75 to 22.0 mg/kg every 12 hours) is a broad spectrum antibiotic,
which is usually well tolerated. Diarrhea and vomiting are noted side effects. Clavulanate has no antibacterial
effects alone, but it is a strong inhibitor of the beta-lactamase enzyme that causes resistance among grampositive and gram-negative bacteria. Some clinicians find the label dose (13.75 mg/kg twice daily) to be less
effective than a higher dose (22 mg/kg twice daily).
Fluoroquinolones are broad-spectrum bactericidal antibiotics. They include enrofloxacin,
ciprofloxacin, marbofloxacin, orbifloxacin, and premafloxacin. Although they are effective in the treatment of
staphylococcal infections, their use should be reserved for the treatment of resistant infections, that is, infections
with gram-negative bacteria (Escherichia coli, Pseudomonas spp, Salmonella spp) and for deep granulomatous
infections with Staphylococcus sp. The fluoroquinolones achieve good penetration into granulation tissue.
The minimum inhibitory concentration (MIC) requirement and dosage requirement for staphylococcal
infections and for Pseudomonas spp is considerably higher than for Escherichia coli and Salmonella spp. When
dealing with Pseudomonas, enrofloxacin (20 mg/kg daily), ciprofloxacin (20 mg/kg daily), and marbofloxacin
(5.5 mg/kg daily) are the best choices. Marbofloxacin has a lower MIC for Pseudomonas sp than the other
veterinary approved drugs. The effectiveness of the fluoroquinolone class of medications is dose dependent;
therefore, a higher dose once daily is recommended over the same dose split twice daily. Potential side effects
of fluoroquinolones in dogs include gastrointestinal upset and cartilaginous defects in growing dogs.
Deep bacterial pyodermas involve tissues deeper than the hair follicle and are generally a continuation
of a superficial infection or superficial folliculitis. The infection goes deeper into the follicles and breaks
through the follicular wall to produce furunculosis and infection of the dermis and often the subcutaneous
tissue. Clinical features will vary but generally dogs will present with erythematous, edematous skin with
crusting and draining tracts.
Antibiotics used for deep pyoderma are similar to those used for superficial infections of the skin.
Many dogs with deep pyoderma, however, particularly with chronic infections or those associated with
demodicosis, may have gram-negative bacteria associated with the infection in addition to Staphylococcus sp.
For that reason, in the case of deep pyoderma, a sample is often collected for culture and sensitivity testing.
Culture samples may be collected in one of two ways: If intact lesions are present and are not ulcerated or
draining, they may be cultured with a culturette. A lesion, such as a pyohemorrhagic bulla, is cleaned lightly
with alcohol; and then the lesion is punctured using a 25-gauge needle. The culturette is touched to the lesion
surface to collect the expressed material and then placed into the sterile tube containing the culture medium. In
many cases of deep pyoderma, there are areas of swelling, erythema, and draining tracts. In such cases, finding
an intact primary lesion is difficult, therefore a biopsy sample is obtained from an area of inflammation in
which the surface is not ulcerated. The surface of the skin is cleaned lightly with alcohol, and a small area of
affected skin is removed either using a punch biopsy or by resection with a scalpel blade. This piece of skin is
then wrapped in sterile gauze that is lightly moistened with sterile saline and placed into a sterile container. The
sample is then submitted to the laboratory for a macerated tissue culture. Alternatively, a transport media may
be used.
As with superficial pyodermas, deep pyodermas do not occur spontaneously in normal dogs and cats.
Successful treatment mandates the identification of the predisposing problem(s).
WHAT ABOUT METHICILLIN-RESISTANT STAPHYLOCOCCAL ORGANISMS?
Methicillin-resistant Staph. pseudintermedius (MRSP) is not a “super bug”. As with the methicillinsensitive Staph. organisms, successful treatment requires the use of an antimicrobial agent to which the bacteria
are sensitive. The treatment period is the same and depends upon the depth of the infection (superficial or deep).
Oral antibiotic choses include doxycycline/minocycline, trimethoprim/sulfas, chloramphenicol, rifampin and
linezolid. An antibiotic available by intravenous administration on is vancomycin. These antibiotics may all be
successful at treating a MRSP if the sensitivity results indicate an appropriate minimum inhibitory concentration
(MIC), however each carries its own set of risk factors and/or cost factors.
Doxycycline (5mg/kg every 12 hours) is bacteriostatic with a broad spectrum of activity including
bacteria, protozoa, Rickettsia, and Ehrlichia. It is usually the drug of choice for treating tick-borne diseases in
animals. Doxycycline administered orally to cats has caused esophageal irritation, tissue injury, and esophageal
stricture. This may be caused by more solid-dose formations (primarily doxycycline hyclate rather than
doxycycline monohydrate) becoming entrapped in the esophagus.
Chloramphenicol (40-50mg/kg every 8 hours for dogs; 12.5-20mg/kg every 12 hours for cats) is a
bacteriostatic drug and it is important to maintain drug concentrations above the MIC for as long as possible
during the dosing period. It is a broad spectrum antibiotic used to treat infections caused by gram-positive cocci,
gram-negative bacilli, anaerobic bacteria and Rickettsia. Of concern is possible bone marrow suppression with
high doses or prolonged treatment. This effect is possible in any species with prolonged use, but cats appear
particularly susceptible. **NOTE: exposure to small doses has caused aplastic anemia in people.
Rifampin (5mg/kg every 12 hours or 10mg/kg every 24 hours) has a high activity against grampositive bacteria but more limited activity against gram-negative bacteria. Rifampin is highly lipid soluble
enters cells easily to concentrate in leukocytes and inhibit intracellular bacteria. Resistance among bacteria (e.g.
Staphylococcus sp.) has been reported to develop rapidly, but this has not been well documented among
veterinary isolates. Hepatotoxicity is seen more commonly in dogs when high doses are administered (10mg/kg
and higher). Elevation in hepatic enzymes may be seen. Urine, saliva, tears, feces, sclera and mucous
membranes may become colored with a reddish-orange color.
Linezolid (10mg/kg every 12 hours) is bacteriostatic and active against streptococci and staphylococci.
It is indicated for treatment of infections that have become resistant to other drugs, particularly when there is
resistance to the beta-lactam antibiotics. It is not indicated for gram-negative organisms. Because of the high
cost of linezolid, it is not used for routine infections. Side effects may include diarrhea and nausea in people, but
because of the limited use in animals, adverse effects have not been reported.